guideline suicide risk management.pdf

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MOH/P/PAK/274.14(GU)


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Ministry of Health Malaysia

GUIDELINE ON SUICIDE

RISK MANAGEMENT IN

HOSPITALS


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This guideline was developed by the Medical Services Unit,

Medical Services Development Section of the Medical Development Division,Ministry of Health Malaysia and the Drafting Committee for the

Guideline for Suicide Risk Management in MOH Hospitals.

Published in February 2014

A catalogue record of this document is available from the library and

Resource Unit of Institute of Medical Research, Ministry of Health;

MOH/P/PAK/274.4(GU)

And also available from the National Library of Malaysia;

ISBN 978-967-0399-85-0

All rights reserved. No part of this publication may be reproduced or distributed

in any form or by no means or stored in an database or retrieval system without

prior written permission from the Director of the Medical Development Division,

Ministry of Health Malaysia.


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Guideline On Suicide Risk Management

v

TABLE OF CONTENTS

1. INTRODUCTION 1

2. DEFINITIONS 1

3. STRATEGIES 2

4. OBJECTIVES 3

5. ENVIRONMENTAL SAFETY 6

6. SUICIDE ASSESSMENT AND TRIAGE 7 6.1 IDENTIFY RISK FACTORS: SCREENING 7

6.2 IDENTIFY PROTECTIVE FACTORS 9

6.3 CONDUCT SUICIDE INQUIRY 9

6.3.1 General Considerations 9

6.3.2 Factors that need to be assessed 9

6.3.3 General Questions before Asking About Suicide 10

6.3.4 Questions to Assess Suicide Intent 10

6.3.5 Questions to Assess for Suicide Plan 10

6.4 MANAGEMENT OF PATIENTS WITH SUICIDAL RISK 11

6.4.1 Triaging for Patients with Suicide Risk 11

6.4.2 Referral for Psychiatry Assessment and Management 12

6.4.3 Indication for Psychiatry Inpatient Management 12

6.4.4 CHECKLIST BEFORE TRANSFERRING PATIENT 13

6.4.5 BEFORE DISCHARGING FROM GENERAL WARD 13

6.5 PROVIDING INFORMATION AND DOCUMENTATION 15 6.5.1 Documentation for Suicide Prevention 15

6.5.2 Other Documentation Guidelines 16

7. POST INCIDENT MANAGEMENT: SUICIDE POST-VENTION 16

7.1 IMMEDIATE ACTIONS 16

7.1.1 Aim 17

7.1.2 Implementation 17

7.2 SHORT TERM TASKS 20

7.3 LONG TERM GOALS 20


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8. TRAINING 22

9. CONCLUSION 22

APPENDIX 1 : SAD PERSONS 23

APPENDIX 2 : SUICIDE CAUTION PROCEDURE 24

APPENDIX 3 : BREAKING OF BAD NEWS 25

APPENDIX 4 : CHECKLIST FOR MANAGEMENT OF INPATIENT SUICIDES 26

APPENDIX 5 : EXAMPLE OF SUICIDE POST-VENTION ACTION CARDS 27

APPENDIX 6 : FLOW CHART FOR THE MANAGEMENT & REPORTING OF

INCIDENTS 30

APPENDIX 7 : TEMPLATE FOR TRAINING 31

SUICIDE IN HOSPITALS AWARENESS & RESPONSE (SHARE) WORKSHOP 31

MODIFIED 22-ITEM SUICIDE OPINION QUESTIONNAIRE (English version) 32

SOALSELIDIK PENDAPAT BERKAITAN BUNUH DIRI (BM Version) 34

ROLE PLAY USING CASE VIGNETTE 36

Case Vignette 1 36

Answer guide for trainer (Case 1) 37

Case Vignette 2 39

Answer guide for trainer 40

APPENDIX 8: EXTERNAL CAUSES FOR INJURY MORTALITY MATRIX (ICD-10) 42

REFERENCES 43

ACKNOWLEDGEMENT 44


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MESSAGE FROM THE DIRECTOR GENERAL OF HEALTH MALAYSIA

Salam Sejahtera dan Salam 1Malaysia

I would like to congratulate the Psychiatric Services of the

Ministry of Health Malaysia for preparing the groundwork

of this guideline; and to everyone involved in the writing

and reviewing process for their commitment, technical

inputs and shared experiences which had resulted in the

production of this important guideline.

With the advent of medical technologies, it is importantfor health professionals to maintain their mindfulness and

empathy towards patients. Patients who self-harm are a

challenge to our values as healers. It is also a challenge to the system, because we are

their custodians. We are bound by our duty to care and duty to protect, so that patients who

receive care in our facilities can move on with their lives, despite the impairments caused by

their ailments.

This guideline is one of the outputs from our Incident Reporting and Learning System, and

illustrates how we can create service improvements at systemic level, with strong clinicalgovernance and willingness to work together as a team. I am optimistic that with the launching

of this guideline, there will be increased awareness and competency levels in handling people

at risk of suicide in our hospitals. This improvement in the quality of care will be in tandem with

the corporate culture movement propagated by the Ministry of Health Malaysia, i.e. Caring,

Teamwork and Professionalism. It is also in line with our Government Transformation Plan

which is deeply rooted in the motto of 1Malaysia i.e. People First, Performance Now .

It is my greatest wish that each and every one of the staff in Ministry of Health will continue to

serve with efciency, genuineness and non-judgmentally, especially when facing patient who

are giving up hope due their chronic health conditions. Let us all give our commitment and

work as a team to implement the recommendations in Suicide Risk Management Guidelines

for the betterment of our services.

Thank you

Datuk Dr. Noor Hisham Bin Abdullah

Director General of Health, Malaysia


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MESSAGE FROM THE TECHNICAL ADVISOR TO THE MINISTRY OF

HEALTH FOR PSYCHIATRY AND MENTAL HEALTH

Assessment of suicide risk and management of suicidal

patients in hospital wards are highly important aspects of clinical

practice that have to be prioritized in all hospitals. Potentially

suicidal patients are managed not only in psychiatric wards but

in medical, surgical and all other wards. It is essential that

all hospital staff, and not only the staff of the Department of

Psychiatry and Mental Health, is trained in the requisite skills

and knowledge of suicide risk management.

These guidelines are a very important step in the improvement

of management of patients with suicidal risk in the hospital.

Even more crucial will be the operationalization of these

guidelines i.e. translating words into daily clinical and nursing practice. For this to be

successful, it is important to have the support of the hospital management, particularly the

hospital director, deputy directors as well as all heads of departments and all levels of staff.

In this regard, on behalf of Psychiatric and Mental Health Services of Ministry of Health

Malaysia (MOH), I would like to thank the Medical Development Division for their collaboration

that has made these guidelines a reality. My appreciation is also extended to the writing team

members who have worked tirelessly to produce a comprehensive guideline. This initiative

was started in Hospital Selayang: the challenge now is in the implementation and also the

dissemination to other hospitals in the MOH.

Thank you.

Dr Toh Chin Lee

Senior Consultant Child and Adolescent Psychiatrist and

Technical Advisor to Ministry of Health for Psychiatry and Mental Health Services


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1. INTRODUCTION

Suicide of a patient while in a staffed, round-the-clock care setting is a rare but devastating

incident. This has been recognised by the Ministry of Health Malaysia (MOH); which has

included inpatient suicide attempts as one of the incidents which requires a mandatory

reporting (1).

Ministry of Health (MOH) staff needs to be aware that their patients have an increased risk

of suicide. Research on these patients proles had identied those who have received a

life-threatening diagnosis and who appear particularly agitated, despondent, or withdrawn;

or patients who have severe, intractable pain (2). Other factors associated with chronic

ill-health e.g. increasing debts, disrupted family ties and loneliness may also put patientsat risk.

The challenge is that, suicide in general medical settings has different characteristics from

suicides in psychiatric inpatients: past history of psychiatric illness, substance abuse or

suicidality is typically absent. Inpatient suicides also tend to be impulsive (3-6). In view of

that, hospitals need to improve the competency of non-psychiatric staff in recognizing mental

health symptomatology and suicidality. This can be facilitated by having adequate training

and screening tools; followed by a referral system for psychiatric consultation servicesfor follow-up of positive responses. The hospital also needs a system that could balance

between the seriousness of medical condition vs. the suicide risk posed by the patient.

This document is in line with the quality assurance practices outlined by the Incident Reporting

and Learning System Manual (IR Manual)1and the Joint Commission on Accreditation of

Healthcare Organizations(7) (JCAHO). These guidelines are not to be construed or to serve

as a standard of care. Standards of medical care are determined on the basis of all clinical

data available for an individual case and are subject to change as scientic knowledge andtechnology advance and patterns evolve.

2. DEFINITIONS

Dening self-harm is not straightforward due to the varying types of self-harm, the different

contexts in which it occurs, and the different motives and meaning for the individual

concerned. The NICE guidelines (National Collaborating Centre for Mental Health, 2004)

1The IR manual can be accessed online athttp://patientsafety.moh.gov.my/uploads/incident_reporting2013.pdf


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use the short and broad denition: Self-poisoning or self-injury, irrespective of the apparent

purpose of the act (8). Meanwhile, the American Psychiatric Association in its practice

guideline for the assessment and treatment of patients with suicidal behaviours gave several

denitions for suicidal behaviours, as listed below(9):2.1. Suicide:Self-inicted death with evidence(explicit or implicit) that the person intended

to die

2.2. Suicide Attempt: Self-injurious behaviour with a nonfatal outcome accompanied by

evidence (either explicit or implicit) that the person intended to die

2.3. Near-miss Suicide Attempt: Potentially self-injurious behaviour with evidence (either

explicit or implicit) that the person intended to die but stopped the attempt before

physical damage occurred

2.4. Suicidal Ideation: Thoughts or serving as the agent of ones own death. It may vary in

seriousness depending on the specicity of suicide plans and the degree of suicidal intent

2.5. Suicidal Intent: Subjective expectation and desire for a self-destructive act to end in death

2.6. Lethality of suicidal behaviour: Objective danger to life associated with a suicide

method or action. Note that lethality is distinct from and may not always coincide with

an individuals expectation of what is medically dangerous

2.7. Non-suicidal self-injury: Direct, deliberate destruction of ones own body tissue without

any intent to die, such as cutting or burning ones own skin

2.8. Intentional self-harm or poisoning:this is the term used to describe suicidal behaviour

in the The International Statistical Classication of Diseases and Related Health

Problems version 10 (ICD-10). The various categories are listed in Chapter XX i.e.

External Causes of Mortality and Morbidity (codes X 60-X 84) (10).

2.9. Inpatient suicide:suicide committed by a medically ill patient who is hospitalized;

within the hospital premises.

3. STRATEGIES

The commitment of an organisation in preventing inpatient suicides can be gauged by

strategies that they use to full certain indicators and steps as outlined in Table 1.

Table 1: Indicators and steps involved for prevention of inpatient suicides

INDICATOR STEPS INVOLVED

INDICATOR 1. The risk

assessment includes

identication of specic factors

and features that may increaseor decrease the risk for suicide

Step 1. Identify risk factors, noting those that

can be notied in the short term to reduce risk;

AND protective factors, noting those that can be

enhanced.Step 2. Ask specically about suicide, suicidal

ideation and history of suicidal behaviour


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INDICATOR 2. The clients

immediate safety needs and

most appropriate setting for

treatment are addressed

Step 3. Determine level of risk/ develop appropriate

treatment setting/ plan to address risk

INDICATOR 3. Providing

information to the relevant

parties

Step 4. Document the assessment, treatment plan

and instructions and adequate management of a

post-suicide event

4. OBJECTIVES

This guideline responds to the general objective of the Incident Reporting and Learning

system, which is to facilitate a learning organisation through the reporting of and learningfrom adverse incidents, "near misses" and hazards so that a just and safe culture will be

nurtured amongst health care providers, in our efforts to enhance the safety of the Malaysian

health care system (1). The scope of this guideline is for risk management of inpatient

suicide/ suicide attempts; thus specic objectives would be:

GENERAL OBJECTIVES DESCRIPTION

4.1 To adopt a collaborative

approach in the prevention ofinpatient suicide

4.1.1 Membership of the suicide risk management

committee may include:i. Hospital Director and other administrative ofcers

ii. Psychiatrist/Psychologist/Counsellor

iii. Specialists from other relevant units e.g. Medicine,

Surgery, Emergency etc.

iv. Matrons and sisters from relevant units

v. Head of Assistant Medical Ofcer

vi. Hospital security Ofcer

vii. Telephone operator

viii. Assistant Environment Health Ofcer

ix. Public Relations Ofcer

x. Information technology ofcer

xi. Medical Record Ofcer secretariat for

documentations

xii. Quality Unit secretariat for the Incident Reporting

Committee, including inpatient suicides


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4.1.2 The role of the suicide risk management committee:

i. To assist the hospital management in the implementation

of Suicide Risk Management policies/ program

ii. To develop hospital-wide strategies andstandardised methods in the prevention of suicide

and manage post-suicide incidents

iii. To assist in the investigation of suicide intent and

follow up on the implementation of corrective

measures to be undertaken

iv. To monitor the incidence of suicide and provide

feedback to the Hospital Incident Report Committee

v. To review and continuously improve suicide risk

managementvi. Frequency of meetings of at least 4 times a year

4.2 To educate staff and

clients (patients and their

relatives) about suicide

awareness

4.2.1 Training objectives for staff:

i. To improve the knowledge-base of doctors with

respect to suicide screening and assessment2i.e.

a. conduct take a thorough history

b. recognize relevant risk factors

c. design and implement a treatment plan that

provides precautions against completed suicide

ii. To increase the comfort level of staff by familiarizing

them with mental health symptomatology

iii. To recommend adequate screening tools for use by

staff

4.2.2 Training objectives for patients and relatives

i. Patients and accompanying relatives with moderateto high risks will be given pamphlets about early

detection of depression and suicidal ideations

ii. Relatives of patients who have high risk or had

attempted suicide are highly encouraged to

accompany patients in the ward

2Simon RI. Psychiatry and law for clinicians. Washington, D.C.: American Psychiatric Press, 1992


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4.3 To provide and maintain

a safe environment to prevent

in-patient suicides

4.3.1 Role of respective clinical and facility managers

To conduct the screening for risk factors and to

assess the physical environment to control patient

access to methods of self-injury (refer Section 5.0)

4.3.2 Role of the psychiatric team

To assist other departments in conducting more

detailed suicide risk assessment for patients who

have current risks of suicide, and determine the level

of intervention; and whether patients need to be

transferred to the psychiatric ward. Re-assessments

will also be conducted depending on clinical needs

4.3.3 Role of nursing staff

To conduct monitoring of moderate to high risk

patients in their respective wards

4.3.4 Role of administrative and record ofcers To facilitate regular training sessions and ensure

environmental safety; and to facilitate the

implementation of recommendations for suicide risk

management

4.4 To establish Service-

preparedness for inpatient

suicides

4.4.1 To ensure that staffs in various locations are able to

provide the following services:

i. Appropriate emergency care is instituted

ii. Management of the dead body

iii. Appropriate debrieng for relatives and attending staff

iv. Carry out a full assessment of the patient prole and

suicidal act; and make recommendations


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5. ENVIRONMENTAL SAFETY

All clinical and facility managers should conduct screening for risk factors and assess the

physical environment to control patient access to methods of self-injury. The most commonmethods of suicide in hospitals are hanging, suffocation and jumping from height. Suicidal

patients in medical units are in less controlled, therefore, higher-risk physical environments;

safety is increased by providing closer observations, often one-to-one with an accompanying

person (5). Areas to focus on:

5.1 Access to means of hanging, suffocation, and strangulation

5.1.1 The xtures (shower heads, light xtures, curtain rods, closet doors, door

knobs) from which something heavy could be suspended 5.1.2 The closets and showers should have break-away rods

5.1.3 Adequate observation for patients who require medical equipment (e.g.

intravenous lines, pulse oximetry )

5.1.4 Shoelaces and belts - may need to be taken from patient

5.1.5 Linen closets are locked

5.1.6 Usage of guitars and other string instruments

5.1.7 Trash can liners in the unit

5.2 Access to jumping from height as a method of suicide

5.2.1 The unit located higher than ground level

5.2.2 Access to windows, balconies, re escapes, any place from which they could

jump

5.2.3 The windows can be opened or are broken

5.3 Access to other potentially harmful items for patients who are at risk of suicide

5.3.1 A body and belongings search done on admission. 5.3.2 A security ofcer is stationed at the ward entrances

5.3.3 The items brought in by visitors should be monitored

5.3.4 Monitoring of patients who have got items such as belts/ glass bottles/

cigarette lighters

5.3.5 Monitoring of cleaning supplies

5.3.6 Electrical outlets in the bathrooms.

5.3.7 Availability of blow-dyers or other electrical appliances.

5.3.8 Monitoring of razor for shaving


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5.4 Challenges to transport ing patients

5.4.1 Whether the reason for taking the patient off the unit is urgently needed or

required. The increased risk associated with the transport should be balanced

by the benet of the procedure. 5.4.2 Consideration of the place of destination regarding its safety whether there is

access to places for jumping or hanging

5.4.3 Consider a higher level of observation for the duration of the time the patient

is away from the more secure unit.

5.4.4 Staff responsible for the observations must be informed of the status of the

patient and aware of their options and level of responsibility for intervening in

a crisis.

5.4.5 Consider adequate sedation before transporting patients.

6. SUICIDE ASSESSMENT AND TRIAGE

6.1 IDENTIFY RISK FACTORS: SCREENING

This is the responsibility of all doctors, especially when receiving patient into their units.

Table 2 lists the stratication of risk factors(11). For a simpler method, doctors can use the

SAD PERSONS scale (refer Appendix 1).

Table 2: Screening for patients at risk of su icide3

SYMPTOMS HIGH RISK MODERATE RISK LOW RISK

At r isk Mental StateDepressed

Psychotic

Hopelessness, despair

Guilt, shame, anger,Agitation

Impulsivity

Severe depression

Commandhallucinations ordelusions about dying

Preoccupied withhopelessness,despair, feelings ofworthlessness

Severe anger,hostility.

Moderate depression

Some sadness

Some symptoms ofpsychosis

Some feelings ofhopelessness

Moderate anger,hostility

Nil or milddepression, sadness

No psychoticsymptoms

Feels hopeful aboutthe future

None/mild anger,hostility.

3To be used as a guide only and not to replace clinical decision-making and practice


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Suicide attempt/thoughtsIntentionality

Lethality

Access to meansprevious suicideattempt/s

Continual / specicthoughts

Evidence of clearintention

An attempt with highlethality (ever).

Frequent thoughts

Multiple attempts oflow lethality

Repeated threats.

Nil or vague thoughts

No recent attempt or1 recent attempt oflow lethality and lowintentionality

Substance disorderCurrent misuse ofalcohol and other drugs

Current substanceintoxication, abuse ordependence

Risk of substanceintoxication, abuse ordependence

Nil or infrequent useof substances

Corroborative HistoryFamily, carers

Medical recordsOther service provider/sources

Unable to accessinformation, unable toverify information, orthere is a conictingaccount of events tothat of those of theperson at risk

access to someinformation

Some doubtsto plausibility ofpersons account ofevents.

able to accessinformation/ verifyinformation andaccount of events ofperson at risk (logic,plausibility)

Strengths & SupportExpressedcommunication

Patient is refusinghelp

Patient is ambivalent Patient accepts help;therapeutic allianceformed

Availabi li ty of suppor tsWillingness/ capacity of

support person/s

Safety of person/ others

Lack of supportiverelationships / hostile

relationshipsNot available/unwilling / unable tohelp

Moderateconnectedness; few

relationshipsAvailable butunwilling/ unable tohelp consistently

Highly connected /good relationships

and supportsWilling and able tohelp consistently

Reective practiceLevel & quality ofengagement

Changeability of risklevel

Assessment condencein risk level

Low assessmentcondence; or highchangeability; orno rapport, poorengagement.

High assessmentcondence / lowchangeability

Good rapport,engagement.

Reviews by Psychiatryteam

At least twice daily At least daily At least weekly

No (foreseeable) risk Following comprehensive suicide risk assessment, there is noevidence of current risk to the person. No thoughts of suicide or historyof attempts, has a good social support network


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6.2 IDENTIFY PROTECTIVE FACTORS

Internal protective factors External protective factors

Good coping and problem-solving skills Strong perceived social supports/ connection

Positive values and beliefs Family cohesion

Ability to seek and access help. Peer group afliation

Spirituality Children or pets at home

Capacity for reality testing Religious prohibition

Reasonable frustration tolerance Positive therapeutic relationships

Hopefulness/ optimism Sense of responsibility

Fear of suicide Receiving mental health care

Fear social disapproval

6.3 IDENTIFY PROTECTIVE FACTORS

6.3.1 General Considerations

i. ASKING ABOUT SUICIDE WILL NOT MAKE THE PATIENT BECOME SUICIDAL

ii. The key is to set the stage for the questions and to signal to the patient that the

questions are naturally part of the overall assessment of the current problem

iii. All these questions must be asked with care, concern and compassioniv. Establish rapport so that patients are more open to talk to us; tips as listed in

Table 3

Table 3: Tips for Establish ing Rappor t

Dos Donts

Engage with the person Dont be judgmental

Be respectful Dont be shocked or embarrassed and panic

Be professional Dont try to cheer the patient by making jokes about his/ hersuicidal thoughts

Be emphatic Dont make the problem appear trivial

6.3.2 Factors that need to be assessed

i. Current mental state and thoughts about death and suicide

ii. Current suicide plan seriousness of intent, methods etc.

iii. The persons support system (family, friends)


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6.3.3 General Questions before Asking About Suicide

Questions to build rapport and serve as an opening for the patient to talk about their

problems and for health care staff to gradually ask about suicide;

i. How do you feel at the moment? (Apa perasaan encik/ puan sekarang?)ii. Is there anything troubling you lately? (Adakah apa-apa merisaukan anda akhir-

akhir ini?)

iii. Do you feel that no one cares for you? (Pernahkah terasa bahawa tiada sesiapa

pedulikan awak?)

Responses that indicates suicidal thoughts and a cry for help

I just cant take it anymore (Saya sudah tak larat lagi)

I cant do anything right(Saya tidak mampu membuat sebarang perkara dengan betul)

I wish I was dead (Saya rasa lebih baik saya mati)

All my problems will end soon (Semua masalah saya akan berakhir tidak lama lagi)

There is no way out (Tiada jalan keluar lagi)

6.3.4 Questions to Assess Suicide Intent

i. I appreciate how difcult this problem must be for you at this time. Some of my

patients with similar problems/ symptoms have told me that they have thoughtabout ending their life. I wonder if you have had similar thoughts.

(Saya maklum kesusahan yang awak tanggung disebabkan masalah ini. Kadang-

kadang ada pesakit lain dengan masalah yang sama berkata yang mereka pernah

terkir untuk menamatkan hidup. Pernahkah kamu terkir perkara yang sama?) ii. When did you have these thoughts?(Bila yang awak terkir begitu?) iii. How often do you have these thoughts? (Berapa kerap awak terkir sebegitu?) iv. Do you think that that your situation is hopeless? (Adakah awak rasa keadaan

awak sudah tiada harapan?) v. Do you have a plan to take your life?(Adakah awak merancang untuk menamatkanhidup?)

vi. Have you had similar thoughts before? (Pernahkah awak terkir perkara yangsama sebelum ini?)

vii. Have you ever attempted to harm yourself before? (Pernahkah awak cuba untukmencederakan diri sebelum ini?)

6.3.5 Questions to Assess for Suicide Plan i. Have you thought of harming yourself? (Pernahkah awak terkir untukmencederakan diri?)


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ii. What have you thought of doing? (Apa yang awak nak lakukan?) iii. Have you come close to acting on this? (Pernahkah awak hampir-hampir

melakukannya?)

iv. Have you made any plan to carry this out? (Pernahkah kamu membuatperancangan untuk melaksanakannya?)v. What has stopped you up until now?(Apa yang menghalang awak setakat ini?)

6.4 MANAGEMENT OF PATIENTS WITH SUICIDAL RISK

6.4.1 Triaging for Patients with Suic ide Risk

The following is a triaging tool developed by the Victorian Government Department of

Human Services(12).

REPORTED BY

PATIENTS

OBSERVATION BY

STAFF

RECOMMENDED

INTERVENTIONS

Low RiskPatients

Some mild or passivesuicide ideation, with nointent or plan

No history of suicideattempt

Available social support

Cooperative;communicative; compliantwith instructions

No agitation/ restlessness

Irritable withoutaggression

Gives coherent history

Suicide caution*

Allow accompanying family/friend to monitor whilewaiting for psy intervention.

Refer to psychiatry from EDor as in -patient referral ifin ward.

Reassessment of suicidalbehaviour as required.

ModerateRiskPatients

Suicide ideation with somelevel of suicide intent, butwho have taken no actionon the plan

No other acute risk factors

History of psychiatricillness & receiving

treatment

Agitated/restlessIntrusive behaviour;bizarre/ disorderedbehaviour

Confused; withdrawn/uncommunicative

Ambivalence about

treatment

Body & belonging search toremove items that could beused for self- harm.

Suicide caution* & ifindicated abscondingprecaution.

Refer to psychiatry from ED

or as in -patient referral ifin ward.

If in medical/surgicalward, encourage family toaccompany.

Reassessment of suicidalbehaviour as required.

High RiskPatients

Made a serious or nearlylethal suicide attempt

Persistent suicide ideation

or intermittent ideation withintent and/or planning

Extreme agitation/restlessness

Physically/ verbally

aggressive

Body & belonging search to

remove items that could be

used for self- harm

BLUE

YELLOW

RED


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High RiskPatients

Psychosis, includingcommand hallucinations

Other signs of acute risk

Recent onset of majorpsychiatric syndromes,especially depression

Been recently dischargedfrom a psychiatric inpatientunit

History of acts/threats ofaggression or impulsivity

Confused/ unable tocooperate

Requires restraint

Violent behaviour

Possession of a weapon

Self-harm in ward

Urgent referral to & rapidevaluation by psychiatry.

Constant staff observationand/or security in ED and in

the wards.Psychiatry inpatientadmission (if medicallystable). If not medicallystable, to managein the ward of originand emphasise onmultidiscipline teamactions & ensure effectivecommunication.

Administer psychotropic

medications and/or applyphysical restraints asclinically indicated

suicide caution*

* Suicide Caution Procedure is available in appendix 2

6.4.2 Referral for Psychiatry Assessment and Management

i. As part of good clinical practice, patient should be informed prior to the referral.

ii. However, if the patient is at risk, the patient should be referred to psychiatry teamdespite his/ her objection.

iii. Notwithstanding, where there are situations when patients has to remain in a

general ward, the Suicide Caution Procedure can be used to monitor their

progress. Appendix 2 describes the general considerations and implementation

methods for this chart.

6.4.3 Indication for Psychiatry Inpatient Management

PSYCHIATRIC IN-PATIENT MANAGEMENT IS INDICATED FOR PATIENTS IN THE

YELLOW AND RED CATEGORIES:

i. After a suicide attempt or aborted suicide attempt if:

a. Patient is psychotic.

b. Attempt was violent, near-lethal, or premeditated.

c. Precautions were taken to avoid rescue or discovery.

d. Persistent plan and/or intent is present.

e. Distress is increased or patients regret surviving.

f. Has limited family and/or social support.

RED


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g. Current impulsive behaviour, severe agitation, poor judgement, or refusal

of help is evident.

h. Change in mental status secondary to changes in medical condition.

ii. Presence of suicidal ideation with

a. Specic plan with high lethality

b. High suicidal intention

c. Severe anxiety and agitation

iii. Admission to inpatient psychiatry ward must be according to Mental Health Act

2001.

CAUTION:

Transfer to psychiatric ward is indicated only after the patient is medically stable.

6.4.4 CHECKLIST BEFORE TRANSFERRING PATIENT

Is the reason for taking the patient off the unit urgently needed or required? The

increased risk associated with the transport should be balanced by the benet of

the procedure

Consider where the patient is going. Is that facility safe? Does the patient have

access to places from which to jump or hang?

Consider a higher level of observation for the duration of the time the patient is

away from the more secure unit

Staff responsible for the observations must be informed of the status of the patient

and aware of their options and level of responsibility for intervening in a crisis.

6.4.5 BEFORE DISCHARGING FROM GENERAL WARD

The psychiatric team has been consulted

Comprehensive suicide risk management has been conducted

Harmful items and lethal medications have been removed.

A supportive person is available and instructed in follow up observation and

communication regarding signs of escalating problems or acute risk.

A follow-up appointment with a psychiatrist and/or psychologist scheduled.

Patient understands the conditions that warrant a return to the emergency

department.


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Figure 1: Risk assessment and tri aging of inpatient suicides


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6.5 PROVIDING INFORMATION AND DOCUMENTATION

6.5.1 Documentation for Suicide Prevention

Document the assessment, treatment plan and instructions to include crisis resourcesfor individuals and their family members

i. Discharge From the

Emergency department

a.

b.

c.

d.

e.

Identify and, if appropriate, contact outpatient support system;

family/ friends

Develop appropriate plan; referral to current treatment providers/

outpatient clinic

Inform patient and/or family/friends (if indicated) about the signs

of increased suicide risk; especially sleep disturbance, anxiety,

agitation, and suicidal expressions and behaviours

There must be a plan to contact signicant support peopleabout the potential suicide risk and follow-up arrangements. All

attempts at contacting should be documented.

If the patient does not wish to permit contact with family, this

should be documented

ii. Transfer from an

inpatient unit to

psychiatry

a.

b.

Patient with high risk shall be transferred to a psychiatric ward

when their medical status allows.

Those with moderate and low risk, with good social support

should be given the option of an outpatient treatment.

iii. Discharge from wards a.

b.

c.

d.

e.

f.

g.

Provide the patient and the family/carer with dischargeinstructions

Explain the uneven recovery path from their illness, especially

depression. e.g., There are likely to be times when you feel

worse that doesnt mean that the medications have stopped

working. Contact your healthcare clinician if this happens

Inform the family/friends (if indicated) about the signs of

increased suicide risk; especially sleep disturbance, anxiety,

agitation and suicidal expressions and behaviours

If the patient does not wish to permit contact with family, thisshould be documented

Provide information for follow-up appointment, which may

include contacting and/or scheduling an appointment

Provide prescriptions that allows for a reasonable supply of

medication to last until the rst follow-up appointment (when

indicated)

Provide information about local resources available, such as

emergency contact numbers and instructions

iv. Suicide risk following

discharge

a.

b.

Suicide risk increases following discharge across diagnostic

categoriesSuicide attempts are also more frequent in the time period

following discharge


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6.5.2 Other Documentation Guidelines

i. When to Document

Suicide RiskAssessments

a.

b.c.

d.

e.

At the time of hospital admission

With occurrence of any suicidal behaviour or ideationWhenever there is any noteworthy clinical change

Before transferring from high dependency setting to a general

ward

Before discharge

ii. What to Document in a

Suicide Assessment

a.

b.

c.

Basis for the risk level (including presence and characteristics of

any suicidal or non-suicidal self-injury thoughts or behaviours)

Treatment plan for reducing the risk, including observations and

other restrictions

Ward round discussions and communications can facilitate

communication as well as risk management

iii. Examples a.

b.

Example of a Physicians Note: This 62 year-old, recently

separated man is experiencing his rst episode of major

depressive disorder. In spite of his denial of current suicidal

ideation, he is at moderate to high risk for suicide, because

of his serious suicide attempt and his continued anxiety and

hopelessness. The plan is to hospitalize with suicide precautions

and medications, consider ECT. Reassess tomorrow.

Example of a Nursing Note: Mr X consistently denied suicidal

ideation this evening when asked. However, he continued topace and ruminate about how he had ruined his life and shamed

his family by making a suicide attempt and being hospitalized.

PRN Lorazepam was given. Patient was restricted to public

area and monitored on 15 minute checks. The Lorazepam was

somewhat effective, after one hour he was sitting still in the TV

room and not pacing.

7. POST INCIDENT MANAGEMENT: SUICIDE POST-VENTION

Despite our best efforts, there may be time when a patient will successfully carry out an

attempt. The main thrust of action at this time is to work together seamlessly to resuscitate,

protect patients dignity and breaking the bad news to the family. Appendix 3 gives an overview

of the actions to be taken.

7.1 IMMEDIATE ACTIONS

Scope: within 24 hours of the event


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7.1.1 Aim:

i. Provide resuscitation if patient is still alive, and ensure patients dignity if

he/ she had died

ii. To ensure immediate activation of emergency response teamiii. Efcient scene management and transfer of victim

7.1.2 Implementation

Table 4 and Figure 2 show the various actions and persons involved in this

process. Inpatient suicide is considered a major event and the reporting

process is summarized in a ow chart in Appendix 6. For details, please refer

to the Incident Reporting Manual 2013(1).

Table 4: Immediate actions following an inpatient suicide attempt

No. Action Responsibility

1. Detection of Event

Upon witnessing or discovering the body of a suicide victim, staff shallremain calm. If patient still alive, to administer Basic Life Support:i. Inform operator/ coordinator via the designated

emergency line

ii. Staff to introduce self to operator: Name, place of work,contact number

iii. Information to be relayed:a. Location of incident/ body foundb. Time of incidentc. Patients condition (dead or alive)d. Patients gendere. Patient is adult or childf. Patients ethnic group

Staff whom rst arrived

at scene or informed by

public

2. Activation of the Suicide Emergency Response Team

Operator shall activate the emergency response teami. Emergency Department via MECC (Medical Emergency Call

Centre) or its equivalentii. Sister on-calliii. Assistant Medical Ofcer Supervisor (Penyelia) on-calliv. Security Ofcerv. Others e.g. Matron on call, Environment Health Ofcer, Public

Relations Ofcer, Deputy Director (Management) to be on thestandby if any needs arise. This is based on local resources andapplicability

Operator/ Coordinator


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3. Immediate medical management

i. If patient still alive, to initiate emergency clinical management.ii. If patient has died, please refer to the steps for management of

dead body and management of death site

Emergency Department

for item (i)

Penyelia on-call to

supervise transfers

(item ii)

4. Immediate Communicat ion

i. Sister on-call to activate network for identication of patient andhis/ her ward of origin via victims wrist tag or other communicationmeans. Once ascertained, information should be relayed to theSecurity Ofcer and the superiors

ii. Sister-on-call to notify Matron-on-calliii. Security Ofcer to notify Hospital Director or Deputy Directoriv. Hospital Director / authorised personnel will lodge a police report

about incident

Sister on call

Security Ofcer

5. Management o f dead body

i. Maintain patients dignity while waiting for police i.e. by shieldingview from passers-by

ii. Provide cooperation for police to conduct investigationsiii. Coordinate transfer of patient from scene to the mortuary

Security Ofcer

(item I & ii)

Forensic team and

Penyelia on-call (item iii)

6. Management of the physical environment

i. Seal / cordon the area where the suicide victim carried out the acte.g. in cases of jumping from height, this should be the windowwhere the victim made his/ her nal exit

ii. Seal and cordon the incident site while awaiting for the policeiii. Provide assistance to the police during investigationiv. Notify the Assistant Environmental Health Ofcer when police had

nished their investigations, so that cleansing process can begin

Security Ofcer

7. Management at ward of origin

i. Sister/ staff nurse to notify medical ofcer in-charge or on-callii. Nurses and doctors need to conrm identity of the victim via facial

identication at siteiii. Sister or team leader to obtain contacts for patients next-of-kin and

compile patients clinical notes and investigationsiv. In cases of jumping from height, staff to identify the exit point and to

secure the area until Security Ofcer and police arrivesv. Medical ofcer to inform the specialist in-charge or on-callvi. Specialist to notify the head of departmentvii. Medical ofcer and/ or specialist to assess staff, patients, and

witnesses at risk for trauma reaction: to pacify them and to referaccordingly

viii. All staff need to make necessary documentation in patient recordsand for incident reporting

Ward staff/s

Ward sister

Medical Ofcer /

Specialist in-charge


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8. Management o f nex t-o f-k in

i. The medical ofcer or specialist in-charge or on-call shall inform thedeceaseds or attempters next of kin (refer Appendix 4.

ii. The specialist shall ensure that there is a staff to escort the next-of-kin to either the emergency department or the mortuary

iii. Next of kin may be referred to psychiatry if necessary

In hospitals with

specialists, this task

need to be carried out

by specialist

9. Management at Forensic Unit/Department

i. Ensure availability of a bereavement room where next-of-kin canwait for the release of the deceaseds remains

ii. Procedure of the release of remains, to adhere to available policy

Multidisciplinary

10. Management of death site after removal of body

i. Handling/ collection of remains/ body parts to refer protocol formanagement of patients with HIV

ii. To ensure the cleaning process done by the cleansing team followsthe standard operating procedure

Assistant Environmental

Health Ofcer

11. Health and Safety Management

i. To investigate ward of origin and death site to identify anyenvironmental or infective disease risk factors.

ii. To instruct the cleansing team to clean the death site according to

the Infection Control Policy, once they receive the go-ahead fromthe Security Ofcer

iii. To ensure that the WEHU A1 and A2 forms are completediv. To notify the incident to the Department of Safety and Health

(DOSH) for the respective state via phonev. Prepare investigative report for the State Health Department and

DOSH

Assistant Environmental

Health Ofcer

12. Universal precaution must be observed at all times by all staff whohas direct contact with the victim

All staff

13. Other relevant ofcers:

i. Psychiatry department : to provide support for next-of-kin or staffwho has acute crisis reaction or other signicant symptoms

ii. Public relations ofcer: to coordinate media communications andcoordinate preparations for press statement if necessary

iii. Hospital administration: Assembles reports from all relevant ofcersand to coordinate post-event meeting, which is chaired by theHospital Director or Deputy Director


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7.2 SHORT TERM TASKS

Scope: within 1 week of the suicide


1. Continued Communication, Cl inical Assessment and Management

Continue conversations with family; offer referral to psychiatry if they

develop serious grief reaction symptoms/ signs

Encourage open communications between patients and staff

Ward sister/ Staff nurse

in charge at ward of

origin

2. Debrieng

Provide counselling to patients and staffs for emotional reactions

these may include those who had to do the body identication and

cleansing (in cases of jumping from height)

Continue monitoring other patients for suicide risk

Doctor-in-charge/ on-call

Location: ward

If necessary, to involve

the psychiatry team

3. Environment of care

Identify and reduce access to lethal means (e.g. windows)

OSHA Committee

Hospital Management

4. Mortality Review

Conduct Root Cause Analysis and create action plan

Ward of origin

Hospital Incident

Committee

5. Other services available

Involvement of other services such as Religious unit at hospital level

eg. BAHEIS (Bahagian Hal Ehwal Islam)

To help next-of-kin and staffs to deal with their emotional reactions from

spiritual perspective when available

7.3 LONG TERM GOALS

Scope: within 1 week of the suicide


1. Communication and Administ ration

Complete changes in Action plan

Avoid excessive clinical and administrative reactions

Create multidisciplinary team to review incident

Suicide Risk

Management

Committee

2. Cl in ical Assessment and Management

Assure adequacy of staff training in depression and suicide.

Avoid undue assessments of patients

Multidisciplinary

3. Environmental aspects

Institute environmental modications as outlined in Action Plan

Incorporate design modications and changes for new construction

OSHA

Hospital management

4 Policy and procedures

Identify legal concernsAddress systemic changes.

Hospital Management


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FLOWCHART FOR POST-INCIDENT MANAGEMENT: RESPONDING TO SUICIDES

IN THE HOSPITAL

Figure 2: FLOWCHART FOR POST-INCIDENT MANAGEMENT: RESPONDING TO SUICIDES IN HOSPITALS


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8. TRAINING

A template for training is available in Appendix 5. The Suicide Risk Management Guideline

Committee recommends that Hospitals Directors in all MOH hospitals to take the lead insuicide risk management for the staff in their respective hospitals. Training should include

inputs on knowledge, attitude and skills; thus there shall be components of information-

sharing, role-play and attitude questionnaires. It should be carried out regularly, e.g. during

the World Suicide Prevention Day which is celebrated globally on 10 September annually.

9. CONCLUSION

The Suicide Risk Management Committee strongly supports the efforts of the IncidentReporting and Learning System committee. This reporting system can lead to learning and

improved safety through generation of alerts; dissemination of "lessons learnt" by health-

care organizations from investigating a serious event; and preparation of reports to identify

unrecognized trends and hazards requiring attention, insights into underlying systems failures

and generate recommendations for "best practices" for all to follow. Inpatient suicide is

one of the incidents graded as RED, and need to be reported to the relevant State Health

Departments within ve working days of the date of occurrence. For all CATEGORY RED

incidents and sentinel events, a full root cause analysis shall be undertaken by the localorganisation and reported to the relevant State Health Departments within 60 working days of

occurrence of the incident.

As outlined by the IR Manual, this guideline has maintained that recommendations shall

be focused on changes in systems, processes or products, rather than being targeted at

individual performance. This is a cardinal principle of safety that must be reinforced by the

nature of recommendations that come from any reporting system; which is based on the

concept that individual error results from systems defects, and will recur with another personat another time if those systems defects are not remedied.

We certainly hope that this national guideline will facilitate the learning process in the risk

management of inpatient suicides.

END


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APPENDIX 1 : SAD PERSONS

The SAD PERSONS scale is an acronym based on 10 suicide risk factors. The scale has found

widespread acceptance in assessing the likelihood of a suicide attempt. However, cliniciansare reminded that suicide risk factors are qualitative (not quantitative) measures that need to

be viewed within the overall clinical presentation.

Factor Points

S = Sex (male) 1

A= Age (45 years) 1

D = Depression 1

P = Previous suicide attempt 1

E = Ethanol abuse 1

R = Rational thinking loss 1

S = Social supports lacking 1

O = Organized plan 1

N = No spouse / signicant other 1S = Sickness (chronic debilitating illness) 1

Score less than 2 : Discharge with outpatient psychiatric evaluation

Score of 3 6 : Consider hospitalization or at least very close follow-up

Score of at least 7 : Hospitalise

Source : Patterson WM, Dohn HH, Bird J et al. Evaluation of Suicidal Patients : the SAD

PERSONS scale. Psychosomatics .1993;24(4): 343-345, 348-349.


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APPENDIX 2 : SUICIDE CAUTION PROCEDURE

This procedure encompasses several steps which include environmental manipulation and

regular review of the patient. Considerations that should be made:1. The procedure is carried out by paramedic staff in the ward

2. Documentation will be made using a Close Observation Form, as below (Source:

Appendix IV, CD Charts H:Psychiatry from the Hospital Information System

Close Observation Chart(Carta Pemerhatian Rapi)

Patients Demographic

Time interval

from initiation

Date Time Patients condition Observation by

0 min

30 min

60 min

90 min

120 min

150 min*add row for every 30 minutes until 1440 minutes (24 hours)

3. Intervention/ Management plan:

a. Placement of patient should be centrally located, preferably near nurses station and

within view of staff

b. Avoid placing patient at the end of cubicle, near exit, or the window

c. Patient is restricted to his/ her area and not permitted to use any thing that may

cause harm

d. Preferably to have one-to-one supervision with staff/ family member at all times,

even when going to bathroom. The latter should know the whereabouts of thesepatients

e. Be especially alert to potentially dangerous items e.g. anything sharp, anything

that can be used for strangulation, anything that can be a danger to self (e.g. glass

containers, scissor, fork, knife, shaver, nail clipper etc.) Also be alert on the possibility

of patients at risk saving up their own medication to harm themselves.

f. Check at frequent and regular interval to ensure safety. This may range between 15

minutes to one hour

g. Ask patient for any plans for suicide, and attempt to ascertain how detailed andfeasible the plans are.

h. Observe and document the patients behaviour pattern, sleep and interaction.


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APPENDIX 3 : BREAKING OF BAD NEWS

Vandekieft (13) had adapted the practical and comprehensive model formulated by Rabow

and McPhee, that uses the simple mnemonic ABCDE

The ABCDE Mnemonic for Breaking Bad News

BREAKING BAD NEWS

Advance preparat ion

Arrange for adequate time, privacy and no interruptions (turn pager off or to silent mode).Review relevant clinical information.Mentally rehearse, identify words or phrases to use and avoid.

Prepare yourself emotionally.

Build a therapeutic environment/ relationship

Determine what and how much the family wants to know.Have family or support persons present, if availableIntroduce yourself to everyone.Warn the patient that bad news is coming.Use touch when appropriate.Schedule follow-up appointments.

Communicate well

Ask what the family already knows.Be frank but compassionate; avoid euphemisms and medical jargon.

Allow for silence and tears; proceed at the family members pace.Have the family member describe his or her understanding of the news

Allow time to answer questions; write things down and provide written information.Conclude the interview with a summary and follow-up plan (e.g. referral to other relevant agencies)

Deal with patient and family reactions

Assess and respond to the familys emotional reactionBe empathetic.Do not argue with or criticize colleagues.

Encourage and validate emotions

Explore what the news means to the familyOffer realistic hope according to the patients goals.Use interdisciplinary resources.

Take care of your own needs; be attuned to the needs of involved house staff and ofce or hospitalpersonnel.


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APPENDIX 4 : CHECKLIST FOR MANAGEMENT OF INPATIENT SUICIDES

Sources: Ballard ED, Pao M, Horowitz L, Lee IM, Henderson DK, Rosenstein DN. Aftermath

of suicide in the hospitals: institutional response. Psychomatics. 2008 Nov-dec; 49(6): 461-9

Communicationand Administration

Clinical Assessmentand Management

Environmentof Care

Policy andProcedures

ImmediateActions

Designate teamleader

Create workinggroup to respondto event

Notify family,

staff, patients,administrators,legal, andregulatory bodies

Decide onpossible medianotication

Identify individualsat risk for suicide.

Assess staff,patients, andwitnesses at riskfor trauma reaction

Decide on possibledebrieng of staff

Identify changesto the ward (e.g.lock unit, checkfor windows andcords)

Interact with

police and medicalexaminer (ifnecessary)

Create emergencyResponsechecklist withitems such asinpatient safety,staff response,

communication,and environment Assess existing

policies andprocedures forimmediate safety

Considerimplementingshort-term unitrestrictions

Short-Term

Tasks

Encourage opencommunicationbetween patientsand staff

Continueconversationswith family

Providecounselling topatients and stafffor emotionalreactions

Maintain mentalhealth presence onall hospital units

Continuemonitoring patientsfor suicide risk

Identify andreduce access tolethal means (e.g.temporary nettingin atrium, barredwindows).

Conduct RootCause Analysisand create Actionplan

Evaluate patientpasses andassessmentpolicies

Decide on policyfor travel costs forfamily members

Long-Term

Goals

Completechanges topolicies in ActionPlan

Avoid excessiveclinical andadministrativereactions

Createmultidisciplinaryteam to reviewadverse events

Assure adequacyof staff training indepression andsuicide

Avoid undueassessment ofpatients

Instituteenvironmentalmodications asoutlined in ActionPlan.

Incorporate designmodications andchanges for newconstruction.

Continueinteractionswith regulatoryagencies.

Identify legalconcerns.

Institute FailureModes and Effects

Analysis.


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APPENDIX 5 : EXAMPLE OF SUICIDE POST-VENTION ACTION CARDS

Pre-requisite:each hospital should designate a specic EMERGENCY NUMBER to enabletheir staff to trigger the response in the fastest manner.

Preamble: these actions cards are in Bahasa Malaysia, which is the usual medium ofinstruction in Ministry of Health Hospitals. The aims at the top of each card are only to servethe purpose of this guideline. This set of action cards are developed in a high-rise hospitalwhere most of the suicides were byjumping from height. The word mangsa (victim) will beused to refer to the person who carried out the suicidal attempt; while pesakit (patient) refersto other patients who are present in that hospital.

ACTION CARDFIRST (1ST) RESPONDER

AIM: TO TRIGGER THE RESPONSEFirst (1st) Responderadalah kakitangan yangmenyaksikan/ mendapat makluman daripada orangawam tentang kejadian.

1. Hubungi:TALIAN KECEMASAN HOSPITAL YANGDIPERUNTUKKAN

2. Maklum operator telefon identiti anda nama/tempat kerja/ no telefon

3. Maklumkan butir-butir kejadian

3.1. Lokasi kejadian3.2. Keadaan mangsa3.3. Bangsa/ jantina mangsa

ACTION CARD'CALL CENTRE' JABATAN KECEMASAN

AIM: IMMEDIATE CLINICAL MANAGEMENT1. Terima laporan tentang insiden daripada telefonis2. Arahkan pasukan kecemasan ke lokasi kejadian

dengan segera3. Pastikan keadaan mangsa4. Jika mangsa masih bernyawa, jalankan

perawatan klinikal kecemasan5. JIka mangsa telah meninggal dunia, maklumkan

Ketua Penyelia Atas Panggilan untukpengendalian mayat dan tempat kematian

6. Sediakan dokumentasi insiden

ACTION CARDOPERATOR TELEFON (TELEFONIS)

AIM: TO DEPLOY THE RESPONSE TEAM1. Terima panggilan daripada First (1st) Responder2. Dapatkan dan lengkapkan maklumat mangsa

pada borang:2.1. Nama pelapor/ lokasi/ no telefon2.2. Lokasi kejadian2.3. Masa kejadian2.4. Keadaan mangsa (hidup/ mati)2.5. Jantina2.6. Dewasa/ kanak-kanak2.7. Bangsa

3. Membuat panggilan kepada:3.1. Call centre Jabatan Kecemasan (MECC)3.2. Penyelia Jururawat Atas Panggilan3.3. Penyelia PPP Atas Panggilan3.4. Pegawai Keselamatan3.5. Pegawai Unit Kesihatan Persekitaran3.6. Pegawai Unit Perhubungan Awam3.7. Penolong Pengarah Pengurusan

ACTION CARDPEGAWAI KESELAMATAN

AIM: SECURITY & NETWORK WITH POLICE1. Terima laporan daripada telefonis2. Maklumkan Pengarah Hospital3. Hubungi ibu pejabat polis terdekat4. Seal/ Cordon lokasi kejadian5. Pastikan dignity mangsa dengan menghadang

mangsa dari pandangan umum6. Cegah orang awam daripada berkumpul/

mengambil gambar7. Tunggu pihak polis datang serta iringi mereka

untuk bantu urusan siasatan

8. Beri clearance kepada Penolong PegawaiKesihatan Persekitaran apabila polis telahselesai siasatan tempat kejadian

9. Sediakan dokumentasi insiden


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ACTION CARDKETUA JURURAWAT ATAS PANGGILAN

AIM: PATIENT IDENTIFICATION & NURSING

SUPERVISION1. Terima laporan tentang insiden daripada

telefonis2. Pergi ke tempat kejadian untuk pengesahan kes3. Telefon semua wad yang berkenaan untuk

pengenalpastian identiti mangsa dan ward-of-origin

4. Apabila telah kenalpasti ward-of-origin,maklumkan kepada Penolong PegawaiKesihatan Persekitaran tentang exit point

5. Laporkan insiden kepada Penyelia Ketua

Jururawat (Matron) Atas Panggilan6. Pantau respons daripada jururawat di ward-of-

origin7. Sediakan dokumentasi kejadian

ACTION CARD PEGAWAI PERUBATAN Y/M/ATAS PANGGILAN WARD-OF-ORIGIN

AIM: CLINICAL INVESTIGATION ANDMANAGEMENT, PREVENT FURTHER RISK

1. Terima laporan tentang insiden daripada KetuaJururawat / team leader dari ward-of-origin

2. Pastikan informasi seperti berikut: 2.1. Lokasi kejadian dan wad asal 2.2. Demogra

2.3. Keadaan mangsa3. Pergi ke tempat kejadian dan buat pengesahan4. Semak rekod pesakit untuk kenalpasti masalah

kesihatan/ risiko pesakit berkenaan dan buatringkasan kes

5. Laporkan kejadian kepada: 5.1. Pakar Y/M/ Atas Panggilan 5.2. Ketua Jabatan6. Hubungi waris mangsa & minta waris datang ke

hospital7. Memeriksa pesakit atau ahli keluarga di wad

yang agitated akibat kejadian dan rujuk keJabatan Psikiatri jika perlu

8. Sediakan dokumentasi insiden dalam rekodperawatan mangsa serta borang insiden

ACTION CARDKETUA JURURAWAT/ TEAM LEADER

WARD OF ORIGIN

AIM: PATIENT AND EXIT POINT IDENTIFICATION,

NURSING MANAGEMENT, PREVENT FURTHERRISK

1. Terima laporan daripada Ketua Jururawat AtasPanggilan

2. Arahkan anggota wad untuk buat head countuntuk kenalpasti pesakit yang missing. Jikaada, beri maklumat identiti mangsa kepadaKetua Jururawat Atas Panggilan

3. Pergi ke lokasi kejadian/ Jabatan Kecemasanuntuk buat pengecaman mangsa

4. Skrin/ kunci lokasi exit point

5. Sediakan maklumat perawatan mangsa sertanombor telefon waris beliau

6. Laporkan kejadian kepada Pegawai PerubatanYang Menjaga (YM) / Atas Panggilan

7. Buat pemerhatian untuck kenalpasti sama adaterdapat pesakit dan keluarga di dalam wadyang agitated akibat kejadian: cuba tenangkandan maklumkan pegawai perubatan

8. Sediakan dokumentasi kejadian dalam notakejururawatan serta borang insiden

ACTION CARD PAKAR PERUBATAN Y/M/ATAS PANGGILAN WARD-OF-ORIGIN

AIM: CLINICAL FORMULATION, NEXT-OF-KINMANAGEMENT, DEPARTMENTAL RESPONSE

1. Terima laporan tentang insiden daripadaPegawai Perubatan Y/M atau Atas Panggilan

2. Pergi ke tempat kejadian dan buat pengesahan3. Dapatkan ringkasan kes daripada Pegawai

Perubatan Y/M atau Atas Panggilan4. Jumpa keluarga kesakit dan jalankan prosedur

breaking of bad news di wad. Pastikan suasanayang kondusif

5. Arahkan Jururawat untuk iringi keluarga JabatanKecemasan atau Jabatan Forensik (berdasarkaninput daripada Penyelia Atas Panggilan) jikaperlu

6. Maklumkan kepada Ketua Jabatan7. Selia dokumentasi kes.


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ACTION CARDPENYELIA PPP ATAS PANGGILAN

AIM: SUPERVISE LOGISTICS AND MOVEMENT

1. Terima laporan tentang insiden daripadatelefonis

2. Pergi ke tempat kejadian untuk pengesahan kes3. Selia perpindahan mangsa daripada tempat

kejadian ke Jabatan Kecemasan atau JabatanForensik

4. Teruskan komunikasi dengan Penyelia diJabatan Kecemasan atau Jabatan Forensikuntuk pemantauan keadaan/ pergerakanmangsa

5. Bertindak sebagai contact person bagimaklumat pergerakan mangsa

6. Sediakan dokumentasi kejadian

ACTION CARDPENGURUSAN

AIM: COORDINATED REPORTING & RESPONSE

1. Terima laporan tentang kejadian daripadatelefonis

2. Kumpul semua laporan dari semua pegawaiyang terlibat

3. Koordinasi mesyuarat dalam selepas stand downyang dipengerusikan oleh Pengarah Hospital /Timbalan Pengarah Perubatan

ACTION CARDPEGAWAI KESIHATAN AWAM

AIM: MANAGE WORK & ENVIRONMENTAL RISK

1. Terima laporan tentang insiden daripadatelefonis2. Terima laporan daripada Ketua Jururawat Atas

Panggilan tentang ward-of-origin3. Lakukan siasatan di ward-of-origin dan lokasi

pendaratan untuk kenalpasti risiko persekitaranatau jangkitan

4. Beri arahan dan selia petugas pembersihanuntuk membersihkan lokasi kejadian mengikuttatacara Infection Control Policy (setelah dapatclearance Pegawai Keselamatan)

5. Laporkan kejadian kepada pihak DOSH negeri

dengan segera melalui telefon6. Isikan borang WEHU A1 dan A2 (penyelia lokasi

/ Jabatan Kecemasan)7. Sediakan laporan siasatan untuk Jabatan

Kesihatan Negeri dan DOSH

* DOSH : Department of Occupational Safety and Health

ACTION CARDPERHUBUNGAN AWAM

AIM: MEDIA MANAGEMENT

1. Terima laporan tentang insiden daripadatelefonis.

2. Dapatkan pengesahan maklumat daripada:2.1. Ketua Jururawat Atas Panggilan2.2. Penyelia PPP Atas Panggilan2.3. Unit Keselamatan.

3. Kawalan Media / siaran media.4. Persiapan Sidang Media dan Jurucakap


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APPENDIX6:F

LOW

CHARTFORTHEMAN

AGEMENT&REPORTINGOFINCIDENTS


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APPENDIX 7 : TEMPLATE FOR TRAINING

SUICIDE IN HOSPITALS AWARENESS & RESPONSE (SHARE) WORKSHOP

MASA AGENDA TASKS

8:00 8:30 Registration Interactive

8.30 8:45 Pre-test: Healthcarers attitude(Modied 22-Item Suicide Opinion Questionnaire)

8:45 9:00 Ofciating ceremony

9.00 9.30 Morning break

9.30 - 10.30 Introduction

- Epidemiology and myths- Importance and objectives of guideline- Impact of health carers attitude- Diagnosis coding

Slides and interactive

discussion

1030 11.15 Primary PreventionInfrastructure: access and safety- Identify risk factors- Identify protective factors

Slides and interactivediscussion

11.15 12.00 Assessment and triaging- General questions- Focused questions: ideas, plans, attempts- Triaging & recommended interventions

Slides and interactivediscussion

12.00 12:45 Post-Incident Management- Immediate: Collaborative & multi-level approach- Short-term and Long-term- Documentation

Slides and KIV videopresentation

12:45 1300 Post-test: Healthcarers attitude Interactive

13:00 14.00 Lunch

14.00 15.30 Practical session identifying risk factors & how to askabout suicide

Case vignettes androle play

15:30 16:30 Post-incident management- Service preparedness & forming prevention team- Action card- Debrieng

Case vignettes androle play

16.30 16:45 Closing ceremony


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MODIFIED 22-ITEM SUICIDE OPINION QUESTIONNAIRE (Engl ish Version)

This questionnaire contains 22 items of questions that assess your opinion regarding suicide.

There are no right or wrong answer. Please tick ( ) column the best describe your opinion.

No Item StronglyDisagree

Disagr ee Slightlydisagree

Slightlyagree

Agree StronglyAgree

1 Suicide is an acceptable way to endan incurable illness

2 If someone wants to commit suicide,it is their right and we should notinterfere

3 Suicidal behaviour in youngerpeople is unacceptable

4 Potentially, every one of us can be asuicide victim

5 Suicide is a selsh behaviour

6 It is the professional duty of thehealth care provider to prevent anysuicidal client from dying

7 Those people who attempt suicideare usually trying to get sympathyfrom others

8 People who attempt suicide areusually mentally ill

9 People should not have the right totake their own lives

10 Suicidal behaviour among youngerpeople is particularly puzzling asthey have everything to live for

11 People who attempt suicide and

live should be required to undertaketherapy to understand their innermotivation

12 Suicidal behaviour can be irritating

13 Suicidal behaviour is particularlydifcult to deal with and requiresspecialist care

14 Further training in the developmentof interpersonal skills would be ofbenet when caring for the suicidal

patient


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15 50% of suicidal persons soughtmedical help within the six monthspreceding the suicide

16 Suicidal behaviour is essentially a

way of crying out for help

17 Suicide attempters who use publicplaces (buildings or bridges) aremore interested in getting attentionthan committing suicide

18 Often, it feels as though suicideattempters are trying to makesomeone else sorry

19 People who talk about suicide oftencommit suicide

20 Suicide attempter are less religiousthan others

21 People who lack family relationshipsare more likely to attempt suicide

22 Once a person survives a suicideattempt, the probability of his/hertrying again is minimal


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SOALSELIDIK PENDAPAT BERKAITAN BUNUH DIRI (BM Version)

Soal selidik ini mengandungi 22 pernyataan yang mencerminkan pendapat anda tentang

tindakan membunuh diri. Tiada jawapan yang betul atau salah. Sila jawab semua soalan. Silatandakan () dalam ruang kosong yang paling tepat menggambarkan pendapat anda.

Bil PernyataanSgt

TidakSetuju

TidakSetuju

AgakTidakSetuju

AgakSetuju

Setuju Sangatsetuju

1 Membunuh diri boleh diterima sebagai carauntuk menamatkan penyakit yang tidakdapat diubati.

2 Jika seseorang mahu membunuh diri,tindakan itu adalah hak mereka dan kitatidak sepatutnya campur tangan.

3 Tingkah laku bunuh diri di kalangangolongan muda tidak boleh diterima.

4 Semua orang berkemungkinan menjadimangsa bunuh diri.

5 Bunuh diri merupakan tingkah laku yangmementingkan diri sendiri.

6 Memang menjadi tanggungjawab anggota

kesihatan untuk mencegah pesakit yangcuba membunuh diri daripada meneruskanniatnya.

7 Mereka yang cuba membunuh diri biasanyaingin mendapatkan simpati orang lain.

8 Biasanya, mereka yang cuba membunuhdiri mempunyai penyakit mental.

9 Sesiapa pun tidak berhak mengambil nyawamereka sendiri

10 Tingkah laku membunuh diri dalamkalangan golongan muda sukar difahamikerana mereka mempunyai masa depanyang cerah.

11 Mereka yang cuba membunuh diri perlumenjalani terapi (rawatan) bagi memahamiapa yang mendorong tindakan mereka.

12 Tingkah laku bunuh diri merupakan sesuatuyang menjengkelkan (irritating)

13 Tingkah laku bunuh diri sukar ditangani dan

memerlukan rawatan pakar

Hospital: ____________

No rujukan peserta: ___


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14 Latihan lanjutan dalam kemahiraninterpersonal adalah berguna untukmenjaga pesakit yang mahu membunuh diri

15 Separuh daripada orang yang cuba

membunuh diri pernah mendapatkanrawatan perubatan dalam tempoh enambulan yang lepas.

16 Tingkah laku bunuh diri merupakan carauntuk meminta pertolongan

17 Mereka yang cuba membunuh diri ditempat awam (bangunan atau jambatan)sebenarnya lebih berminat untuk menarikperhatian

18 Sering kali saya berasa mereka yang cuba

Membunuh diri ingin membuatkan oranglain berasa kesal

19 Mereka yang menyuarakan hasratuntuk membunuh diri selalunya akanmelakukannya

20 Mereka yang cuba membunuh diri tidakmempunyai pegangan agama yang kuat

21 Mereka yang tidak mempunyai hubungankekeluargaan yang baik lebih cenderunguntuk cuba membunuh diri

22 Apabila seseorang terselamat daripadacubaan membunuh diri, kemungkinanuntuknya mencuba lagi adalah rendah


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ROLE PLAY USING CASE VIGNETTE

Case Vignette 1

Madam A, 60 year old widow has been in the palliative ward for 1 month due to recurrent

infected stoma. She was diagnosed to have carcinoma of colon 3 years ago with liver

metastasis which gradually deteriorated with substantial blood loss. She underwent a

corrective surgery to secure the bleeding in which a stoma was performed subsequently.

She required several admissions due to infected wounds and resulted with intensive care

in the hospitals.

She was always accompanied by the daughter and occasionally by the grandchildren

during school holidays. They were afraid to leave her unattended in the ward, thinking the

condition may turn critical suddenly. She required multiple analgesics including opioids toaddress the pain in which she became drowsy most of the time. She had to be assisted in

almost all aspects of her personal needs including hygiene and meals. She hardly moved

around and only conned to her bed.

For the past 2 weeks, she was noted to be more withdrawn, less talking to the staff during

bed making, no interest to talk about her daily activity. She seldom talked with the family

during visiting hours and was noted by the staff to be quiet and not interested to engage in

conversations. She preferred to be alone and at times cried for attention when in pain. She

used to mention about feeling no hope to recover this time.

This morning, Mdm A whispered to the nurse the wish to end her life. She was not able tobear the pain and felt helpless. She wished she could ask the doctors to stop the treatment

and to allow her to go home. She did not want to burden her children and would want to join

her deceased husband very soon. She wanted to end her suffering and said that she had

the right to make such decision. Since that afternoon, she refused to take any medication

and remained quiet during the session with the doctors. The family started to worry with the

change and informed the doctor.

Questions

1. Describe how you feel about this patient

2. List down the following

a. Risk factors

b. Protective factors

3. How do you determine the level of risk?

4. How do you approach this patient

a. General questions

b. Focused questions

5. How do you manage this patienta. Psychiatric diagnosis

b. Biopsychosocial intervention


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Answer gu ide for trainer (Case 1)

1. Participants shall describe their own feeling and explain underlying reasons for such

feeling.

2. a. Risk factors : Age,(elderly), Widow; prolonged illness (Ca Colon); complicated

course of illness (multiple operations, admissions, pain); evolving depressive

symptoms

b. Protective factor: Strong family support (always being accompanied); tolerance to

pain ( only revealed pain during high intensity); no active suicidal behaviour ( most

of the time conned to bed)

3. The patient level of risk will be YELLOW - moderate risk; due to the following features: a. Reported:

Suicide ideation with some level of suicide intent, but without proper plan/ action

b. Observed

Withdrawn

Less talking to the staff during bed making

No interest to talk about her daily activity

Seldom talked with the family during visiting hours

Quiet and not interested to engage in conversations

4. Approaching patient

First build rapport with patients-introduce yourself. Be respectful, professional and

empathetic during assessment.

a. General questions:

How do you feel at the moment?

Is there any different the way you feel about your current emotion?

What do you think about things which make you feeling like this?


Questions to assess suicide intent

Some people would think that they could stop the suffering by wishing that they were

better not to live anymore, does this also run into your mind currently?

We have noticed that you seemed to be less interactive with us or your children,

what has bothered your mind?

I guess you have taken such a considerable moment to inform our staff about yourwish to die, please tell us why do you have such thought this time?


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Questions to assess for suicide plans

You are not eating adequately ever since you mentioned this, do you think this is

your plan how you can carry out your wish?

How do you think that you would want this to happen/take place?

How long that you have been thinking like this?

5. Management

a. Diagnosis: Major Depressive Disorder

b. Biopsychosocial approach

Biological

General well-being: ( electrolytes, liver function test, Full Blood Count)

Delirium: (orientation, organization of thought, uctuation of behavior) Role of antidepressant: (SNRI, TCA)

Role of adequate analgesics :( breakthrough opioids, fentanyl patch)

Psychological

Pain assessment Visual Analogue Scale (VAS)

Distress Thermometer (DT)

Hamilton Rating Scale for Depression (HAMD)

Social Family support to provide reassurance to patient

Family grief information KIV non aggressive CPR

Collaboration with religious experts

Ward Clinical/Nursing process

To relocate patient to the cubicle near the nurses counter

To put behaviour chart for close monitoring

To assist patients personal needs ( hygiene, meals, positioning)

Doctors to review at least daily


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Case Vignette 2

Miss MA, 18 years old girl, a college student, single, come from a broken family, was

admitted to surgical ward for stabbing her abdomen with a knife. This is her third attempt.The rst two episode of self-harm was overdosing herself with paracetamol and sleeping

tablets.

She has been having on-going conict with her mother. The father had left the family when

she was only 2 years old and never met him since. She is very close with her maternal

grandmother who was taking care of the patient when the mother goes to work. She also

has a 15-year-old younger sister.

The patient had a quarrel with her mother a day before the incident over her relationship

with her boyfriend. The mother did not approve the relationship because she believed

that he has bad inuence on her. This was shown by her deterioration in her academicperformance and her increasing hostility towards the mother. In the morning of the incident,

she posted on Facebook on her intention to die. She was alone during the attempt. She

had locked the door. Her mother who was alerted by the patients friend went home and

found that her door was locked. Mother had to nd a key to open the door. Patient was

brought to the hospital immediately. In casualty, the patient was not cooperative, refused

to talk and was avoiding eye contact. The grandmother reported that the patient was noted

to be withdrawn, reduced oral intake and poor sleep at night for the past two months. She

also conveyed to her grandmother on few occasions that her life is not worth living.

Questions

1. Describe how do you feel about this patient?

2. List down the following

a. Risk factors

b. Protective factors

3. How do you determine the level of risk?

4. How do you approach this patient a. General questions


5. How do you manage this patient

a. External coding

b. Biopsychosocial intervention


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Answer guide for trainer (Case 1)

1. Participants described their feelings towards the patient. Ask them to explain why they

think the particular feeling developed

2. a. Risk factors : Age,(


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Questions to assess for suicide plans

Have you thought of harming yourself?

What have you thought of doing?

Have you come close to acting on this?

Have you made any plan to carry this out?

What has stopped you up until now?

5. Approaching patient

a. Diagnosis: External code X 78 Intentional self-harm by sharp objects

b. Biopsychosocial approach

Biological

Blood investigation (FBC,RP,LFT, Thyroid function)-Routine and TRO organic cause of

depression,

Start patient on antidepressant in view of prominent depressive symptoms for the past

2 months

Psychological

Educate patient on problem solving skills

Educate on coping skills and strategies Supportive psychotherapy

Family therapy

Social

Improve patient social network- link with NGO such as befrienders


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APPENDIX8:E

XTERNALCAUSESFORIN

JURYMORTALITYMATRIX

(ICD

-10)


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3. Farberow NL. Suicide Prevention in the Hospital. Hosp Community Psychiatry. 1981

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11. NSW Department of Health. Determining suicide risk level. Framework for Suicide RiskAssessment and Management for NSW Health Staff. North Sydney: NSW Health; 2004.

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12. National Institute of Clinical Studies. Emergency department mental health triage tool

and worksheet. Victorian Emergency Department Mental Health Triage Project 200506

training manual. Melbourne: Victorian Government Department of Human Services; 2007.

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13. Vandekieft GK. Breaking Bad News. American Family Physician. 2001;64(12):1975-8.


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Documents

guideline suicide risk management.pdf